Accepted Article Preview: Published ahead of advance online publication

Impact of dietary nutrient intake and physical activity on body

composition and growth in Indian children

Anuradha V Khadilkar, Shashi A Chiplonkar, Neha A

Kajale, Veena H Ekbote, Lavanya Parathasarathi, Raja
Padidela, Vaman V Khadilkar

Cite this article as: Anuradha V Khadilkar, Shashi A Chiplonkar, Neha A Kajale,
Veena H Ekbote, Lavanya Parathasarathi, Raja Padidela, Vaman V Khadilkar,
Impact of dietary nutrient intake and physical activity on body composition and
growth in Indian children, Pediatric Research accepted article preview 20
December 2017; doi: 10.1038/pr.2017.322.

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Received 4 January 2017; accepted 9 October 2017; Accepted article preview

online 20 December 2017

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Cover Page

Title: Impact of dietary nutrient intake and physical activity on body composition and

growth in Indian Children

Running title: Effect of diet on BC in Indian children

List of Authors:

Anuradha V Khadilkar 1*,

Shashi A Chiplonkar 1,

Neha A Kajale 1,

Veena H Ekbote1,

Lavanya Parathasarathi 1

Raja Padidela2,

Vaman V Khadilkar1,

Institutional affiliations:

1. Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute,

Jehangir Hospital, Pune, India.

2. Department of Paediatric Endocrinology, Royal Manchester Children’s hospital,

Manchester, UK.

*Corresponding Author:

Name: Dr. Anuradha Khadilkar,

Address: Deputy Director, Hirabai Cowasji Jehangir Medical Research Institute, Old

Building Basement, Jehangir Hospital, 32, Sassoon Road, Pune, Maharashtra, 411001, India.

Phone numbers: ++ 91 (20) 26057004.

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E-mail address: anuradhavkhadilkar@gmail.com

Financial statement: No financial assistance received.

Conflict of Interest: None Declared

Category of study: Clinical research original article

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Manuscript:

Title: Impact of dietary nutrient intake and physical activity on body composition and

growth in Indian Children

Running title: Effect of diet on BC in Indian children

Abstract:

Objective: To investigate inter-relationships of dietary-composition and physical activity

(PA) with growth and BC in urban Indian school-children.

Methods: A cross-sectional study was performed in 4747-Indian school children (2623-

Boys) aged 3-18 year. Weight, height, BC by body impedance analyser, PA and dietary food

intakes by questionnaire method were recorded.

Results: Mean daily energy and protein intakes as Recommended Dietary Allowance (RDA)

were significantly lower in both boys and girls (p<0.01) above 6-years, with 55% reduction

in micronutrient intakes in older children. When compared to WHO-references, lower heights

in pubertal boys and girls were related to dietary energy and protein intake. Multiple

regression analysis showed positive association of height for age Z-scores (HAZ) with mid-

parental height z-scores (β=0.45, p=0.0001) and protein density (β=0.103, p=0.014). HAZ

was negatively associated with inactivity (β= -0.0001, p=0.049) in boys and girls (R2=0.104,

p<0.01). Further, body fat percentage was negatively correlated with moderate or light

activity and antioxidant intakes (p< 0.01) but not with dietary fat intake. Percentage muscle

mass was positively correlated with moderate activity and negatively with inactivity

(p<0.05).

Conclusion:
Adequacy of protein and antioxidant intakes, reducing inactivity and increasing moderate

activity are essential for optimal growth and body composition in Indian children.

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Introduction

As a result of the nutrition transition, developed as well as developing countries such

as India, are facing the dual challenge of childhood obesity and nutrient deficiencies.

Changing dietary practices such as consumption of fast-foods, sweetened beverages and

energy dense food increases the risk of nutrient imbalance thus leading to childhood obesity.

Further, the global prevalence of overweight and obesity in youth is on the rise (1) including

in India (2).

It has also been observed that Asian Indian children and adolescents have a higher

body fat percentage at lower BMI values (3). Available evidence also suggests that Indian

children and adolescents have inadequate dietary intakes of energy and protein but not fat (4)

(5). High fat intake of Indian youth may be one of the reasons for their adiposity, since fats

have greater energy density of (9 Kcal/g) than that of proteins and carbohydrates (4 Kcal/g)

and the fat content of the diet has been reported to have an effect on body fat as a function of

the effect of dietary fat on energy intake (6) . However, evidence also suggests an inverse

relationship of dietary carbohydrate intake (6)(7) and both a positive and inverse relationship

of protein intake with body fat (8)(9) . Further, these imbalances in nutrient intake may,

together with resulting in adiposity/obesity, also affect growth in adolescence.

Nutrition and growth are integrally related; inadequate nutrient intake during growing

years may reduce or arrest linear growth and also act as a stepping stone for diseases in later

life (10). It has been recently observed that growth in Indian children remains less than

optimum in comparison with children from western countries (11). This suggests that ‘more

than adequate fat intake’ alone, does not guarantee adequacy of energy intake. This is

supported by studies reporting dietary deficiencies of energy, protein, vitamins and minerals

in Indian children and adolescents (12)(5) . Thus, a balance in diet composition appears to be

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more important than the intake of individual nutrients to achieve optimal growth and reduce

the risk of obesity.

A positive energy balance also implies that dietary energy intake is higher than the

energy expenditure. Lack of physical exercise and sedentary lifestyle are the leading factors

for obesity in both adults and children (13)(14) . Therefore, a high-fat diet with low physical

activity would necessarily result in a positive energy balance, thus promoting adiposity even

after considering the energy cost of weight gain (in growing years this is 1% of the total

energy requirement) (15) . However, associations of dietary fat intake and energy intake with

percentage body fat are not consistently observed in studies(16) (7) . Moreover, the effects of

growth and development may interact with diet composition or physical activity, or both, in

ways that are not yet well understood.

Several studies have shown that children who spend more time watching television

have a higher BMI and body fat percentage and are less physically active (17)(18) . On the

other hand, urban Asian Indian adolescents who participate regularly in outdoor games have

been shown to have a lower prevalence of obesity with the risk being three times higher in

those not participating in out-door games (19) .

Taken together, urban Asian Indian children and adolescents have changing dietary

practices and an increasingly sedentary lifestyle which puts them at a higher risk of obesity

and disturbances in growth. Studying interrelationships between nutrient adequacy, physical

activity, body composition and growth may help in understanding means by which growth

and body composition may be optimized. These interrelationships may be masked with

exogenous factors such as socio-economic status (SES). Girls from low SES have been

shown to have significantly higher nutrient deficiencies than girls from higher SES group (5).

Thus, studying these relationships where exogenous factors can be minimized is important.

Therefore, our aim was to study associations of nutrient intake and physical activity with

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body composition and growth in Asian Indian children (Figure 1) from higher SES and to

compare their growth with international growth data. Our specific objective was to

investigate the linkages between nutrient intakes and physical activity with body composition

and growth in 3-18-year-old apparently healthy Indian children.

Methods:

Selection of participants:

This was a part of a multicentre cross sectional study in 3 to 18-year-old Indian children (July

2010 to January 2012). To capture all geographical locations of India, five zones as suggested

by the Indian Academy of Pediatrics were considered for data collection (20) . One major

city, based on per capita income from each of the five zones (Chennai-South India, Delhi-

North India, Kolkata-East India, Pune-West India, Raipur-Central India) was selected. A list

of schools catering to children of socioeconomically well-off families was made for each city

with the help of local co-investigators. Six schools were then randomly selected from each

city and were approached for permissions to carry out measurements.

On a random sample of 4747 school children (2623 Boys), data on anthropometry, diet (one-

day recall (21), body composition by Tanita bio-impedance analyser (22), physical activity by

standardized questionnaire (23) were recorded. The study was approved by the Ethics

Committee of the Hirabai Cowasji Jehangir Medical Research Institute. Written institutional

consent was obtained from the Principals of all schools and written informed consent was

obtained from parents before the study was commenced.

Clinical examination (including a general physical examination and an assessment of the

cardiovascular and respiratory system) were carried out by paediatricians to assess health

status of the children. Children with major illness, or any known condition affecting growth

were excluded from the study.

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Anthropometric Measurements:

Standing height was measured with a portable stadiometer (Leicester Height Meter; Child

Growth Foundation, London, United Kingdom; range, 60-207 cm) with the child barefoot.

Weight was measured with a portable electronic scale (Salter India, Faridabad, India)

accurate to 100 g (calibration performed using standard weights). Body mass index (BMI)

was calculated, and height for age z-scores (HAZ), weight for age z-scores (WAZ), and BMI

for age z-scores (BAZ) were computed using Indian reference data as well as the WHO

references (20) (24) . To account for changes in anthropometric measures associated with

increase in age and associated pubertal changes, as well as the later growth spurt in boys,

following age groups were defined: boys A (3-5 years) , B(6-12years ) , C(13-15 years) , D

(16-18 years ) , girls as A( 3-5 years), B (6-9 years) , C (10 -14 years) , D (15-18 years) (25).

Body Composition:

Body composition was assessed using Bioelectrical Impedance Analyser (BIA), Tanita

Model BC-420MA after a minimum of 3 hours of fasting and voiding before measurements

(10 am onwards) (22) . Body composition of the subjects was assessed on the BIA by

measuring the impedance to electric current passed through the body in a standing position.

The body composition parameters assessed were fat percentage, fat mass, fat free mass, total

body water, bone free lean tissue mass (LTM) and bone mass. Body composition

measurements were tested for test-retest reliability on a pilot sample of thirty subjects

separately by measuring them on BIA at two different time points within a day. Reliability

coefficient was significant for the body fat percent, fat mass, fat free mass and muscle mass

(intraclass correlation coefficient = 0.96, p < 0.001). Using the body fat reference curves by

McCarthy et al, 2006, individual child’s percentile of body fat% was computed by

interpolation and extrapolation techniques (26) .

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Dietary Intake Assessment:

Information on children’s daily food intakes was collected by a self-administered 24 hr diet

recall on one weekday (21) in English language. Choices of common food items consumed

for each region were provided in the questionnaire to enable accurate reporting of diet recall.

After the dietary data were collected, detailed recipes of most commonly consumed food

items were recorded from parents or care givers for each region. The portion size was

obtained by the average of actual weights of one serving of each food item from their

households. This was done for each of the recorded food items. Moisture and the nutrient

contents of the newly developed recipes were estimated. Based on moisture correction;

nutrient contents for the modifications were estimated. Further, in a subset of households, to

estimate the portion sizes of foods, the average cups and measures of each region were

converted to standard cups and measures. The portion size was converted to weights by

weighing each food item in the household.

Validation of the dietary intakes by one-day dietary recall (reported by parents) against the

average of dietary intakes from 24-hour, 3-day diet recalls (2 non-consecutive days and a

holiday) by interview method was conducted in a subset of 20 children at each center.

One day diet recall questionnaire was self-administered by the parents of the children while

the 3-day diet recalls were collected by a trained nutritionist by using ‘multiple pass

approach’ (27)(28). The reliability coefficient was significant for all the food groups (Intra

class correlation coefficient ranged from 0.81 to 0.98 for different food intakes p<0.05).

Daily nutrient intakes were estimated with the use of C-Diet software version 2.0(29) which

comprises of nutritive values of cooked foods (30) ,(31 ),(32) and raw food database of

National Institute of Nutrition (NIN), India (33) and USDA (32) . Moisture and the nutrient

contents of the new recipes were estimated. Based on the moisture correction, nutrient

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contents for the new recipes from all the regions were estimated and used for computing

nutrient intakes.

For assessing the nutrient adequacy of the diet, percentage intake of recommended dietary

allowance (RDA) for Indians as given by the Indian Council of Medical Research was

calculated for all the nutrients (33) . To examine the relationship of dietary nutrient intakes

and growth in terms of HAZ children were categorised in one-yearly age groups.

Physical Activity:

Physical activity was assessed using the QAPACE school children questionnaire (23) by

interview and school schedules. The questionnaire was adapted for Indian children and

adolescent’s lifestyle since commonly played sports and type of religious activities in India

were different, sections pertaining to these activities were modified from the QAPACE

questionnaire. Time spent by the participant in sports activities (jogging, swimming, dancing,

brisk walking, school sports/games and playing outdoor games) was considered as moderate

activity (34). For inactivity, the total amount of time spent in watching television, using

laptops or mobile phones for playing games, chatting, and other sedentary behaviour was

estimated. The reliability analysis comparing responses by self-administration of

questionnaire and by face to face interview in a subset of 30 children revealed the intra-class

correlation coefficient of 0.94 for inactivity and 0.99 for moderate activity (p<0.01).

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Statistical Analysis:

Statistical analysis was performed using SPSS (version 21.0, 2012, SPSS Inc, Chicago, IL).

Normality of the outcome variables was tested using Kolmogorov-Smirnov test. For non-

normal variables, nonparametric tests were used. Comparison of diet and body composition

of different age-sex groups was done using one-way ANOVA with post hoc multiple

comparison tests. Pearson’s product moment correlation coefficient or Spearman’s rank

correlation coefficient were used to estimate association of dietary and anthropometric

variables. Multiple linear regression analysis was performed to examine the simultaneous

effect of diet and physical activity on body composition parameters and growth.

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Results:

Data on the anthropometric and body composition parameters of 4747 (2623 boys) of

apparently healthy children (without history of any chronic disease) aged 3 – 18 years are

described in four age groups (Table 1). Except the first age group, boys had higher mean

values of height and weight than girls (p <0.05). As per the current Indian growth references,

mean HAZ was 0.08 ± 0.02 in boys and 0.14±0.02 in girls indicating that majority of children

and adolescents (85.9%) were within the reference range for height for age. Mean WAZ was

0.07±0.02 in boys and 0.14±0.02 in girls and mean BMIZ was 0.04±0.02 in boys and

0.08±0.02 in girls. As per the WHO cut offs for weight, 80.6% children were within the

reference range, 15.7% were overweight and 3% were obese (35) Body fat percentage was

higher and percentage muscle mass was lower in girls than boys in all age groups (p<0.01)

(Table 1).

Physical activity:

In boys, the average time spent in moderate physical activity was more in older age groups

(A:328± 20 min/week vs D:417±19 min/week) whereas in girls, moderate activity was lesser

in older age groups (A:324±18 min/week vs D:244± 15 min/week) (p<0.01). Inactivity in

boys was more in older age groups (A: 462 ± 20 min/week vs D:610±26 min/week) (p<0.05).

However, minutes spent in inactivity were similar in younger and older girls (A:442± 21

min/week vs D:508± 25 min/week) (Figure 2).

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Diet composition:

Mean nutrient intakes in boys and girls were similar in age group A (3-5 yrs) (Table 2). In

later age groups, boys had significantly higher intakes of majority of nutrients (p<0.05).

There was a gradual rise in absolute nutrient intakes from lower age group A to higher age

group D. Mean percent calories from fats (24.2± 5.1%) and carbohydrates (65.2± 5.8%)

remained similar in all age-sex groups.

Adequacy of nutrient intakes and growth status across age groups:

Energy and protein intakes expressed as percent recommended daily allowances (RDA)

showed significant reduction after 6 years’, in both boys and girls (p<0.01) (Figure 3a &b).

Mean daily micronutrient intakes in boys were around 83% of RDA till 9 years of age and

then gradually reduced to 55% up to 18 years. In girls, mean daily micronutrient intakes

were lower than boys and were around 79% up to 9 years of age and declined to 44% at 18

years of age. Height for age Z scores in the recruited children using Indian references were

higher than those using WHO reference charts (24) throughout the age range. However, both

the HAZ scores were closer during 7 to 11 years in boys and 7 to 10 years in girls (Figure 3a

and 3b). In boys around 14 years, HAZ by Indian references showed an increase after which

there was a decline till 18 years of age (Figure 3a). On the contrary HAZ by WHO

references showed a sharp decrease from 11 years of age (Figure 3a). The reduction in

dietary energy and protein intake goes hand in hand with HAZ by WHO after 12 years of age

but not so with HAZ by Indian references.

In girls, the peak at 12 years in HAZ Indian references and the decline in HAZ by WHO

after 10 years was smaller than in boys (Figure 3b). Corresponding downward trends in

energy and protein intakes were sharper than in boys.

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Linkages of Diet, Physical activity and body composition:

Correlations between percentage body fat and daily energy intake, fat intake, percentage

of dietary energy from fat and carbohydrates in all children were low (r = -0.02 to r = -0.04)

and remained low and statistically non-significant (p>0.1) even after adjusting for age in both

boys and girls (p>0.1). Moreover, correlations of body fat percentile estimated by McCarthy

reference centiles (26), and dietary energy or fat intakes were also found to be low and

statistically not significant in all children. However, in girls, daily antioxidant intake showed

a negative correlation (r = -0.14, p<0.01) with body fat percentile.

Muscle mass percentage and bone mass showed significant correlation with energy (r

=0.14) and protein intakes (r=0.16), (p<0.05) which did not remain after adjusting for age,

underlining the influence of age on diet.

In yearly age groups, moderate activity in minutes per week was high in higher age

groups (p< 0.01). Inactivity in minutes per week was higher than the moderate activity at all

ages from 3 to 17 years. In girls, moderate activity was lower than in boys and much less than

their inactivity throughout the age range (Figures 4a & 4b). Percent body fat and inactivity

were closer till 14 years of age in boys. Around 15 years’ age there was a decline in percent

body fat with a corresponding rise in moderate activity. In girls, percent body fat and

inactivity were closer though the moderate activity remained same throughout till 18 yrs.

A multiple linear regression analysis for body fat percentile revealed that in boys, there

was a positive association of inactivity (β =0.012, p =0.031), and negative association of

moderate activity (β = -0.078, p = 0.047) with body fat percentile (R2= 0.22, p< 0.01).

Whereas, in girls, a negative association of antioxidant micronutrient intakes (% of energy) (β

= -3.46, p= 0.024) and light activity (β = -0.07, p = 0.15) with body fat percentile (R2= 0.19,

p< 0.05) was observed.

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Multiple linear regression for percentage muscle mass indicated a positive association of

moderate (β = 0.031, p =0.095) and light activity (β = 0.01, p =0.025) and negative

association with inactivity (β = - 0.002, p =0.047) in boys. In girls, a positive association of

moderate (β = 0.006, p =0.024) and light activity (β = 0.02, p =0.0001) with percent muscle

mass was observed. These linkages remained significant after adjusting for age. However, no

associations with dietary intakes were found to be significant.

Multiple linear regression analysis for HAZ as a growth indicator suggested a positive

association of mid-parental height z score (β = 0.45, p = 0.0001), protein density (β = 0.103,

p =0.014), and a weak negative association of inactivity (β = -0.0001, p =0.049) in boys and

girls (R2= 0.104, p< 0.01).

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Discussion:

The study population was apparently healthy children and adolescents from urban

upper socioeconomic class covering five zones of India. Dietary energy and protein intakes

were found to be adequate in the early years in both boys and girls; however, there was a

decline in energy adequacy and dietary protein intake around 10 - 11 years which is the usual

age of the adolescent growth spurt. This may hamper achieving target height in these youths.

Micronutrient intake also reduced around this age; this may also potentially impact growth,

development and health.

In line with intakes in early years, the height for age (HAZ) scores as per the Indian

references remained around zero till 12 years in boys and 10 years in girls. However, from

12-16 years of age, HAZ scores were higher in both boys and girls and were below zero at 16

years in both genders. While corresponding with Indian HAZ scores, HAZ scores based on

WHO data showed a gradual decline from peri-pubertal age in boys and girls suggesting that

Indian children and adolescents fell short of WHO reference population along with reduction

in total energy and protein intake. Pubertal stage may confound the relationship of age with

growth and body composition. Thus, lower HAZ may also be explained on the basis of later

puberty, however, studies suggest that timing of puberty in urban affluent Indian children is

similar to that in children in developed countries (36). Our data thus suggest that dietary

inadequacy during adolescent years may be a factor contributing to suboptimal growth in

Indian children and adolescents compared to WHO data. With nutrient adequacy, peak HAZ

would possibly have been higher than the current value.

The finding that mid parental height was a significant predictor of HAZ underlines the

contribution of genetic factors towards final height either in isolation or by modulating

nutrient intake and onset of puberty. In line with our results, midparental height (MPH) has

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been shown to be correlated with a child’s current height and MPH has been used to correct

for genetic potential and to identify non-familial short stature (37).

Body fat increases with age until puberty. At puberty sex hormones induce a

pronounced sexual dimorphism: boys gain proportionately more muscle and lean tissue as

compared to fat, and girls lay down fat as a natural part of the ontogeny of their sexual and

reproductive physiology (26). Our data also exhibit an increase in body fat percentage till 13

years of age and then a decline after 14 years in boys but not so in girls.

Though dietary energy and protein intakes were lower than the RDA, they were not

significantly associated with body fat or muscle mass percentage. Our results did not exhibit

any significant relationship between fat intake as a proportion of energy intake and

percentage body fat. This was further corroborated by the lack of any significant difference

between mean percentage body fat across the dietary energy and fat intake quartiles for boys

and girls separately (p>0.1). Similar findings have been previously reported in preschool

children and adolescents (38). Dietary carbohydrate intake as a percentage of energy intake is

often inversely related to body fat percentage in overweight or obese children (6)(7). This is

possibly due to lower energy density of carbohydrate than fat. However, in the present study,

there was no association between carbohydrate intake and percentage body fat. Possible

reason could be, energy intakes of children above 6 years of age in current study were less

than RDA, indicating that intake of carbohydrate also were not in excess amounts to be stored

as body fat. This is in agreement with other studies on school children (38). Upon further

examination, no significant associations were obtained in the subsets of overweight or obese

children in the current study cohort.

In an earlier cross sectional study, we have found that girls with short stature (HAZ

<– 2) had significantly lower micronutrient intakes in comparison to the required RDA (5) .

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In the present study, micronutrient intakes were found to be low in both boys and girls

throughout childhood years and were 44 to 68% of the RDA around puberty.

Many cross-sectional (39) and longitudinal (40) studies indicate that increased

physical activity and decreased sedentary behaviour are protective against relative weight and

fatness gains over childhood and adolescence. Moreover, high adiposity and low moderate

activity have been found to pose cardio-metabolic risk in youth(39). In the present study, 63

% 6-12-year-old boys (45 % girls) and 73 % older boys (46 % girls) were engaged in

moderate activity for 45 min/day for more than 3 days per week. Moderate activity showed

an inverse relation with body fat percentage in both boys and girls. Around 47 % boys and 41

% girls spent more than 420 minutes/week on TV viewing/computer time. Our results also

demonstrate that inactivity has positive association and moderate activity negative association

with body fat.

The strength of our study is that we have measured interrelationships of body

composition and growth with diet and physical activity over a wide age range of Indian

children from 5 zones of India. Data were collected by the same team at all places and

detailed record of physical activity, diet was performed. These data may help to optimize

growth and body composition in Indian children. However, being a cross sectional study, our

study can only provide information on the possible associations among diet, physical activity

with growth and body composition and cannot describe causal relationships of adiposity with

diet and activity. The other limitation of our study is that diet and activity assessments were

performed using one-day recall and questionnaire method which can offer short term

measures and may not be representing the participant’s habitual diet or activity level. The

one-day recalls were however validated against three-day recalls. Further, growth and

pubertal status play a significant role in body composition measurements; however, since this

was a school based study, we were not able to assess sexual maturity and genetic factors.

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In summary, our data demonstrate that total dietary energy and fat intakes as also percent

energy from fat or carbohydrates were not related to the body fat or muscle mass percentage.

Reduced nutrient intakes with a high fat intake contribute to the higher body fat percentage

coupled with suboptimal growth in Indian children. Adequacy of protein and antioxidant

intakes, reducing inactivity and increasing moderate activity are essential factors for optimal

growth and body composition in Indian children.

Financial statement: No financial assistance received.

Conflict of Interest: None Declared

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References:

1. World Health Organization. Global strategy on diet, physical activity and health:

childhood overweight and obesity. Available from

http://www.who.int/dietphysicalactivity/childhood/en/ (2012).

2. Pandit D. Overweight and obesity prevalence and body mass index trends in Indian

children. 2010;(April):1–9.

3. Pandit D, Khadilkar A, Khadilkar V. Clinical Medicine : Pediatrics Body Fat

percentages by Dual-energy X-ray Absorptiometry corresponding to Body Mass

Index cutoffs for Overweight and Obesity in Indian children. Cinical Med Pediatr.

2009;3:1–7.

4. Tupe R, Chiplonkar SA. Diet patterns of lactovegetarian adolescent girls: Need for

devising recipes with high zinc bioavailability. Nutrition [Internet]. 2010;26(4):390–

8. Available from: http://dx.doi.org/10.1016/j.nut.2009.05.018

5. Chiplonkar S, Khadilkar A, Pandit-Agrawal D, Kawade R. Influence of micronutrient

status and socioeconomic gradient on growth indices of 2 – 18-year-old Indian girls.

2013;26:825–32.

6. Gazzaniga JM, Burns TL. Relationship between diet composition and body fatness,

with adjustment for resting energy expenditure and physical activity, in preadolescent

children. Am J Clin Nutr [Internet]. 1993 Jul [cited 2017 Jan 2];58(1):21–8. Available

from: http://www.ncbi.nlm.nih.gov/pubmed/8317384

7. Tucker LA, Seljaas GT, Hager RL. Body fat percentage of children varies according

to their diet composition. J Am Diet Assoc [Internet]. 1997 Sep [cited 2017 Jan

2];97(9):981–6. Available from:

http://linkinghub.elsevier.com/retrieve/pii/S000282239700237X

8. Vinknes KJ, de Vogel S, Elshorbagy AK, Nurk E, Drevon CA, Gjesdal CG, et al.

© 2017 Macmillan Publishers Limited. All rights reserved.

 20

Dietary Intake of Protein Is Positively Associated with Percent Body Fat in Middle-

Aged and Older Adults. J Nutr [Internet]. 2011 Mar 1 [cited 2017 Jan 2];141(3):440–

6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21248195

9. Ledoux TA, Watson K, Barnett A, Nguyen NT, Baranowski JC, Baranowski T.

Components of the diet associated with child adiposity: a cross-sectional study. J Am

Coll Nutr [Internet]. 2011 Dec [cited 2017 Jan 2];30(6):536–46. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/22331689

10. Srilaxmi B. Dietetetics. Delhi: New age international (P) limited; 2005.

11. Khadilkar V, Khadilkar A. Revised Indian Academy of Pediatrics 2015 growth charts

for height, weight and body mass index for 5-18-year-old Indian children. Indian J

Endocrinol Metab [Internet]. 2015;19(4):470. Available from:

http://www.ijem.in/text.asp?2015/19/4/470/159028

12. Srihari G, Eilander A, Muthayya S, Kurpad a V, Seshadri S. Nutritional status of

affluent Indian school children: what and how much do we know? Indian Pediatr

[Internet]. 2007;44(3):204–13. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/17413196

13. Lioret S, Touvier M, Lafay L, Volatier J-L, Maire B. Dietary and physical activity

patterns in French children are related to overweight and socioeconomic status. J

Nutr. 2008;138(August 2007):101–7.

14. Bowen L, Taylor AE, Sullivan R, Ebrahim S, Kinra S, Krishna KR, et al.

Associations between diet, physical activity and body fat distribution: a cross

sectional study in an Indian population. BMC Public Health [Internet].

2015;15(1):281. Available from: http://www.biomedcentral.com/1471-

2458/15/281/abstract%

15. Food and Agricultural Organization. Human energy requirements: Report of a Joint

© 2017 Macmillan Publishers Limited. All rights reserved.

 21

FAO/WHO/UNU Expert Consultation. FAO Food Nutr Tech Rep Ser [Internet].

2001;0:96. Available from: http://www.fao.org/docrep/007/y5686e/y5686e08.htm

16. Fulton JE, Dai S, Steffen LM, Grunbaum JA, Shah SM, Labarthe DR. Physical

Activity, Energy Intake, Sedentary Behaviour and Adiposity in Youth. Am J Prev Med

2009;37(1):S40–9. Available from: http://dx.doi.org/10.1016/j.amepre.2009.04.010

17. Giammattei J, Blix G, Marshak HH, Wollitzer AO, Pettitt DJ. Television Watching

and Soft Drink Consumption. Arch Pediatr Adolesc Med 2003;157:882–6.

18. Suresh V, Rupnath K, Ramesh V R, M R, T, Sambasivarao KRS. Television watching

and sleep promotes obesity in urban and semi-urban children in India. J Toxicol

Environ Health 2011;3 :001–7.

19. Laxmaiah A, Nagalla B, Vijayaraghavan K, Nair M. Factors Affecting Prevalence of

Overweight Among 12- to 17-year-old Urban Adolescents in Hyderabad , India.

Obesity (Silver Spring) 2007;15(6): 1384-90.

20. Khadilkar VV, Khadilkar AV, Cole TJ SM. Cross-sectional Growth Curves for

Height, Weight and Body Mass Index for Affluent Indian Children, 2007. Indian

Pediatr 2009 ;46(6):477-89.

21. National Cancer Institute, Dietary assessment primer, Available from :

https://dietassessmentprimer.cancer.gov/approach/table.html

22. Kyle UG, Bosaeus I, Lorenzo AD De, Go M, Lilienthal B, Deurenberg P, et al.

Bioelectrical impedance analysis — part II : utilization in clinical practice. Clin Nutr

2004:23;1430–53.

23. Barbosa N, Sanchez CE, Vera JA, Perez W, Thalabard J-C, Rieu M. A physical

activity questionnaire: reproducibility and validity. J Sports Sci Med [Internet].

2007;6(4):505–18. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/24149485%5Cnhttp://www.pubmedcentral.nih.

© 2017 Macmillan Publishers Limited. All rights reserved.

 22

gov/articlerender.fcgi?artid=PMC3794492

24. Anthroplus WHO, Computers P. WHO AnthroPlus for Personal Computers Manual

Software for assessing growth of the world â€TM s children. Available from

www.who.int/childgrowth/software/en/

25. Desai MP, Colaco P. Growth Hormone Deficiency and Insensitivity. In: Desai MP,

Menon PSN, Bhatia V, eds. Pediatric Endocrine Disorders. 2nd ed. Hyderabad,

Universities Press (India) Pvt. Ltd; 2008:188-92.

26. McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM. Paediatric Highlight, Body fat

reference curves for children. Int J Obes 2006: 30 ;598–602.

27. Rutishauser IHE. Dietary intake measurements. Public Health Nutr 2016; 8:1100–7.

28. Guenther PM, Kott PS, Carriquiry AL. Community and International Nutrition

Development of an Approach for Estimating Usual Nutrient Intake Distributions at

the Population Level 1 , 2. J Nutr 1997;127 :1106–12.

29. C-Diet. C- Diet. Pune: Xenios technology; 2012.

30. Chiplonkar SA, Agte VV. Extent of error in estimating nutrient intakes from food

tables versus laboratory estimates of cooked foods. Asia Pac J Clin Nutr [Internet].

2007 ;16(2):227–39. Available from http://www.ncbi.nlm.nih.gov/pubmed/17468077

31. Kulkarni SA, Ekbote VH, Sonawane A, Jeyakumar A, Chiplonkar SA, Khadilkar AV.

Beneficial Effect of Iron Pot Cooking on Iron Status. Indian J Pediatr [Internet]. 2013

19;80(12):985–9. Available from: http://link.springer.com/10.1007/s12098-013-1066-

32. Composition of Foods Raw, Processed, Prepared USDA National Nutrient Database

for Standard Reference, Release 23. 2010;(September).

33. Gopalan, C, Ramasastri BV, Balasubramanian SG. Nutritive value of Indian Food.

National I. Hyderabad: (Indian Council of Medical Research; ICMR); A report of the

© 2017 Macmillan Publishers Limited. All rights reserved.

 23

expert group of the Indian Council of Medical Research. Nutrient requirement and

recommended dietary allowances for Indians, 2009.

34. Centre for disease control and prevention. How much physical activity do children

need? [Internet]. [cited 2016 Oct 25]. Available from:

https://www.cdc.gov/physicalactivity/basics/children/

35. World Health Organisation , Available from :

http://www.who.int/childgrowth/standards/weight_for_age/en/index

36. Agarwal DK, Agarwal KN, Upadhyay SK, Mittal R, Prakash R, Rai S. Physical and

sexual growth pattern of affluent Indian children from 5 to 18 years of age. Indian

Pediatr. 1992 ;29(10):1203-82. Review.

37. Cole TJ. A simple chart to identify non-familial short stature. Arch Dis Child. 2000

;82(2):173-6.

38. Atkin L, Davies PSW. Diet composition and body composition in preschool children

1 , 2. Am Soc Clin Nutr. 2000;72:15–21.

39. Janssen I, LeBlanc AG. Systematic review of the health benefits of physical activity

and fitness in school-aged children and youth. Int J Behav Nutr Phys Act [Internet].

2010 May 11 [cited 2017 Jan 2];7(1):40. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/20459784

40. Must A, Tybor DJ. Physical activity and sedentary behavior: a review of longitudinal

studies of weight and adiposity in youth. Int J Obes (Lond) [Internet]. 2005 Sep [cited

2017 Jan 2];29 Suppl 2:S84-96. Available from:

http://www.ncbi.nlm.nih.gov/pubmed/16385758

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 24

Figure legends:

Figure 1: Inter relationships of growth and body composition with age, gender and
lifestyle factors

Figure 2: Weekly Physical activity across gender and age groups.

Figure 3a and 3b: Dietary energy and protein adequacy and height z scores across age

groups in boys and Dietary energy and protein adequacy and height

z scores across age groups in girls

Figure 4a and 4b: Percent Body fat and physical activity in boys and Percent Body fat
and physical activity in girls

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 Table 1: Body composition of the study cohort a

Age n Muscle Percent Per

group Per cent mass b muscle cent
Gender Height b Weight b Body Fat Fat Free (kg) mass b bone
* Age (yr) (cm) (Kg) (%)b Mass b (kg) (%) mass b
A 254 5.0±0.7 108.2±9.4 18.1±4.2 10.4±6.7 17.1±2.1 16.4±2.0 85.8±6.6 3.7±0.3
Boy (3-5 yr )
B 1705 9.5±2.0 135.9±13.2 33.2±11.2 16.6±11.2 26.6±7.0 25.4±6.6 79.5±10.9 3.9±0.5
(6-12 yr)
C 506 14.4±0.9 164.2±8.7 55.1±13.0 18.5±12.4 43.2±6.5 41.0±6.2 77.1±11.8 4.3±0.6
(13-15
yr)
D 158 16.7±0.6 168.9±6.8 62.0±14.4 16.6±8.2 51.1±8.3 48.5±8.0 79.0±7.8 4.4±0.6
(16-18
yr)
A 226 5.1±0.6 108.7±7.7 18.1±3.9 14.9±6.4 16.6±2.1 15.9±2.0 81.4±6.3 3.7±0.2
Girl (3-5 yr)
B 781 8.0±1.2 126.5±9.6 26.6±7.3 18.7±9.0 21.4±4.2 20.4±4.0 77.3±8.7 3.9±0.3
(6-9 yr)
C 855 12.1±1.3 149.5±9.0 43.1±10.6 25.5±8.7 32.9±5.0 31.0±4.6 70.2±8.3 4.3±0.4
(10-14
yr)
D 262 16.0±0.8 157.3±5.5 53.3±10.9 30.4±5.7 37.5±4.7 35.2±4.4 65.6±5.5 4.0±0.3
(15-18
yr)
Foot notes: a Values are expressed as Mean± SD
b. Differences in successive age groups were statistically significant by one-way ANOVA post hoc multiple comparison test.
Gender differences in body measurements were significant after 5 years of age.
*(p<0.01)

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 Table 2: Mean daily nutrient intakes in boys and girls across age groups

Boys Girls
Age group Age group
Nutrient
intake per A B C D A B C D
day a* 3-5 yr 6-12 yr 13-15 yr 16 -18 yr 3-5 yr 6-9 yr 10-14 yr 15 -18 yr
Energy
(Kcal) 1457±485 1668±559 1776±620 1688±623 1396±449 1522±527 1659±615 1402±554
Protein (g) 41.6±14.2 46.8±16.3 49.0±17.9 45.6±18.1 40.2±13.7 43.0±16.2 45.2±17.0 36.5±13.8
Fat (g) 38.1±15.1 45.7±18.6 46.1±19.3 42.6±20.2 37.8±16.1 41.3±7.5 43.8±19.7 36.8±19.5
Calcium
(mg) 572±236 670±304 688±335 649±367 591±617 617±292 653±332 563±317
Zinc (mg) 4.8±1.8 5.5±2.0 6.1±2.6 5.9±2.3 4.5±1.6 4.9±2.1 5.2±2.1 4.4±1.8
Iron (mg) 7.3±3.1 8.7±3.7 9.4±4.1 9.2±4.0 6.9±3.1 8.0±3.6 8.2±3.7 7.0±3.5
Copper
(mg) 1.1±0.4 1.4±0.5 1.5±0.6 1.4±0.6 1.1±0.4 1.2±0.5 1.4±0.6 1.2±0.5
Vitamin C
(mg) 40±22 45±27 43±29 37±25 39±22 45±29 47±32 35±23
Riboflavin
(mg) 0.76±0.3 0.79±0.3 0.77±0.3 0.68±0.3 0.77±0.3 0.75±0.3 0.75±0.4 0.59±0.3
Thiamine
(mg) 0.60±0.2 0.72±0.3 0.73±0.3 0.66±0.3 0.58±0.2 0.67±0.3 0.72±0.3 0.58±0.2
Niacin (mg) 9.4±3.2 11.3±4.1 12.5±4.4 12.3±4.5 8.9±3.2 9.9±3.7 11.0±4.3 9.4±4.0
Beta
carotene
(microgram) 1316±829 1662±1070 1821±1245 1876±1290 1285±786 1612±1140 1717±1112 1461±1062
Folic acid
(microgram) 76.9±39.8 85.2±38.4 92.9±42.1 91.8±45.2 70.8±30.7 80.0±39.3 82.8±40.8 73.4±39.2
Foot note: a: Values are expressed as Mean± SD, Dietary nutrient intakes increased with age in both boys and girls after 5 yr till 15 yr

* (p<0.05).

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